Midwives’ perceptions of enablers and barriers of quality maternal healthcare in a rural public hospital in the Northern Cape Province

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Moloko-Phiri, Rorisang M. Machailo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8243812/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Midwives who practice in rural public hospitals mostly depend on each other during work. Continuous clinical development improves their skills when managing pregnant women from antenatal to postnatal care. This study aimed to explore and describe the midwives’ adjustment to enablers and barriers of quality maternal healthcare in a selected rural public hospital in the Northern Cape Province, South Africa, and how quality assurance can be maintained throughout. Methods A qualitative, exploratory, descriptive, and contextual approach was used. Data was collected through focused group discussions, using a semi-structured interview guide, adopting a non-probability purposive sampling technique of 23 participants (midwives and accoucheurs) with at least one year of working in the maternity ward at a selected rural public hospital in Northern Cape Province, South Africa. A thematic data analysis was used, with trustworthiness ensured through dependability, confirmability, credibility, transferability, and authenticity. Ethical considerations were maintained. Findings: Two main themes were identified, namely Theme 1: midwives’ adjustment to enablers of quality maternal healthcare, with two sub-themes: passion for midwifery and continuous teamwork, including consistent learning and clinical development in midwifery. Theme 2, midwives’ barrier to quality maternal healthcare, identified four sub-themes: lack of human resources, lack of material resources, inadequate and outdated hospital infrastructure and delayed emergency medical response for maternity care. Conclusion Midwives mostly rely on their passion and teamwork for maternal health services. Cooperative efforts contribute to providing quality healthcare to the mother and child, regardless of the negative experiences. Challenges such as lack of equipment, inadequate midwives, outdated hospital infrastructure and delayed emergency medical response for maternal healthcare form part of the barriers to quality maternal health care. Even though midwives are equipped with skills in caring for the mother and child through antenatal, intrapartum and postnatal care, many barriers still limit them from providing holistic quality nursing care. Therefore, fundamental support is still needed to improve the midwives at the selected rural public hospital. Enablers barriers maternal healthcare worker quality healthcare rural public hospital BACKGROUND The shortage of trained and experienced midwives in rural public hospitals remains a concern in the world [ 15 ]. Governments need to implement strategies for the training and retention of midwives in rural healthcare facilities that provide maternal and childcare services [ 3 ]. Literature suggests that in rural healthcare facilities, most midwives are complaining of burnout, shortage of human and physical resources, including poor working conditions due to old infrastructure [ 13 , 23 ]. Research conducted in the African countries and Southeast Asia highlighted that midwives are working in environments that lack essential resources and equipment [ 4 , 24 ]. Meanwhile, the increased workloads, shortage of midwives and compromised quality of neonatal care in rural hospitals of the Limpopo province in South Africa are of concern [ 16 , 24 ]. [ 25 ] highlighted that, in the Northern Cape Province of South Africa, there has been challenges in the local rural hospital and that more moms and babies would not survive due to the old hospital infrastructures posing a direct risk to the lives of patients and staff. However, in rural South African settings, the severe shortage of midwives results in high workloads, fragmented care, and limited time to provide individualised, woman-centred support. Both teamwork and passion for midwifery ensure that midwives provide holistic quality care to mother and child from conception until birth [ 7 ]. A key component of midwifery practice in South Africa is passion and teamwork. Research across the world has depicted that teamwork and passion are the drivers of holistic and quality care for mother and child in maternal healthcare. However, these should not be the only determiners of retention of staff in the maternal health environment. Advanced training for midwives and good working conditions needs to be urgently implemented in rural public hospitals [ 1 ]. The World Health Organisation (WHO) has reported that midwifery profession has many challenges, which includes lack of equipment, treatment materials and patients of limited financial means face disadvantages because of these challenges. These challenges further put more burden on the already overwhelmed midwives. Despite these challenges, young people still pursue nursing as a career, and do not do it with a good heart but prioritise money more, which is not the way to become a good midwife. Therefore, improvement and advocacy in rural public hospitals where midwives practice need attention. The provision of staff, resources, and advanced training for midwives needs to be urgently attended to. Literature affirms that in-service education, continuing professional development, and advanced training for midwives who provide maternal healthcare in rural public hospitals have proven to enable midwives to give quality care to women and their newborn babies [ 12 ]. Well-trained midwives can respond immediately to complicated births; hence, training these midwives is vital. Addressing human and material resources scarcity in underserved maternal healthcare facilities can improve maternal and neonatal health outcomes [ 2 ]. Maternal and newborn health greatly depends on the dedication and collaboration of midwives. Their dedication and cooperative efforts continue to move midwifery practice forward, greatly enhancing the health of mothers and children nationwide. The delivery of holistic patient care in rural hospitals is significantly compromised by structural health system challenges, including the shortage of midwives, inadequate material resources, outdated hospital infrastructure, and delayed emergency response systems. Holistic care in midwifery involves a comprehensive approach that integrates physical, emotional, social, and psychological support for women and their newborns throughout the perinatal period. This workforce gap not only compromises routine maternity care but also impairs the management of obstetric emergencies, where coordinated team responses and efficient referral systems are vital. The burden placed on overextended midwives is further exacerbated by the lack of essential supplies and equipment, such as oxygen cylinders, sutures, transport trolleys, and neonatal resuscitation tools, which are frequently unavailable or poorly maintained in rural facilities. These resource gaps obstruct safe emergency stabilisation before transfer and delay necessary interventions during critical periods, placing both maternal and neonatal lives at risk. The outdated hospital infrastructure, including unreliable electricity, poor sanitation, and inadequate road access, plays a central role in delaying emergency responses and limiting the functionality of referral systems in rural areas. Many rural hospitals lack operational emergency rooms, efficient communication systems, or functional ambulance bays, all of which are essential for prompt and effective emergency care coordination. The result is frequent delays in ambulance response and prolonged transfer times to tertiary care centres. This delay is detrimental during life-threatening conditions such as eclampsia, uterine rupture, or severe haemorrhage, where time-sensitive interventions are critical. Midwives are left to manage emergencies with limited capacity, leading to emotional exhaustion, moral distress, and professional dissatisfaction. Moreover, patients and families experience heightened anxiety, fear, and distrust toward the health system, undermining their overall experience of care. These factors collectively hinder the midwives’ ability to provide holistic, respectful, and safe maternity care, highlighting the urgent need for systemic investment in rural healthcare infrastructure, workforce development, and emergency response mechanisms. METHODS Study design A qualitative, explorative, descriptive and contextual design was followed. This allowed researchers to compare verbal data with observed data and draw conclusions from the midwives’ adjustment enablers and barriers stated by midwives in selected rural public hospitals [ 6 ]. Study population and sampling The targeted population included all professional nurses who are maternal healthcare workers at the selected rural public hospital, with an experience of more than 12 months as a midwife. A non-probability purposive sampling technique was adopted as it is related to the experiential phenomenon of the research study. The sample included 23 midwives and accoucheurs, who both consented to participate in the study and a total of four focused groups. Study setting The study was conducted at the selected rural public hospital of the Northern Cape Province of South Africa. The hospital has one maternity ward, which provides antenatal, labour, and postnatal services. Day patients and high-risk clinics use the same ward. The ward has a total bed occupancy of thirty-five (35), which are: eleven (11) antenatal beds, eighteen (18) postnatal beds, and six (06) delivery beds. The surrounding clinics refer all patients who are in labour to the selected rural public hospital. Selection criteria Only professional nurses who are maternal healthcare workers and employed in the maternity ward for more than one year at the selected rural public hospital participated in the study, so that they could share correct midwives’ adjustment to enablers and barriers while practising at the hospital. All practising professional nurses who are maternal healthcare workers were registered with the South African Nursing Council (SANC) and have a current practising licence. Both men and women who are professional nurses and work as maternal healthcare providers at the selected public rural hospital were included in the study. Table 1 Demographic data of midwives Participant Qualifications Health facility 1 -Bachelor’s degree in nursing science (BNSc). -Advanced diploma in midwifery. Maternity ward of the selected hospital 2 -Bachelor’s degree in nursing science (BNSc). Maternity ward of the selected hospital 3 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 4 -Diploma in Nursing. -Advanced diploma in midwifery. Maternity ward of the selected hospital 5 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 6 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 7 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 8 -Bachelor’s degree in nursing science (BNSc) Maternity ward of the selected hospital 9 Diploma in Nursing with Midwifery. -Advanced Diploma in midwifery. Maternity ward of the selected hospital 10 -Bachelor’s degree in nursing science Maternity ward of the selected hospital 11 -Diploma in Nursing with midwifery. -Advanced Diploma in midwifery. Maternity ward of the selected hospital 12 -Bachelor’s degree in nursing science (BNSc). -Advanced midwifery. Maternity ward of the selected hospital 13 -Bachelor’s degree in nursing science (BNSc). -Advanced midwifery. Maternity ward of the selected hospital 14 -Bachelor’s degree in nursing (BNSc). -Advanced midwifery. Maternity ward of the selected hospital 15 -Diploma in Nursing with Midwifery. Maternity ward of the selected hospital 16 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 17 -Diploma in Nursing with Midwifery. Maternity ward of the selected hospital 18 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 19 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 20 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 21 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 22 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital 23 -Diploma in Nursing with midwifery. Maternity ward of the selected hospital Data collection For the study the researchers developed their own interview schedule, and the research assistant distributed the invitation and consent forms after all the permissions had been received. The focus group interviews were conducted in a secluded room inside the maternity ward. A voice recorder and field notes were used during the focus group discussions with permission from the participants. Data was collected from 23 participants, all maternal healthcare workers practising at the selected rural public hospital for more than one year. Four focus group discussions (FGD) were conducted with 5 to 6 participants per group. Both male and female participants were included, within the age range of 24 to 60 years. All the participants hold the following qualifications: Bachelor’s degree in nursing, a Comprehensive Diploma in Nursing, a diploma in nursing and midwifery, including an advanced Diploma in midwifery as approved by the South African Nursing Council. SUPPLEMENTARY FILE 1: DATA COLLECTION TOOL/INTERVIEW SCHEDULE All participants will be asked the following main questions and other questions will be directed by the participants’ response. What are the perceptions of midwives regarding the enablers of quality maternal healthcare in a rural public hospital in the Northern Cape Province? What are the perceptions of midwives regarding the barriers towards quality maternal healthcare in a rural public hospital in the Northern Cape Province? The following questions will be used as follow-up questions: What is the quality of maternal healthcare at this hospital? Please tell me more about the barriers you have experienced in delivering quality maternal healthcare as a midwife in this hospital. Are the facilitators or enablers that you have experienced that help you deliver quality maternal healthcare? If so, can you tell me more? Tell me more about your experiences as a midwife in this hospital. Do you have any recommendations for midwives regarding delivery of quality maternal healthcare in this hospital? Data analysis Thematic data analysis was used, which includes six steps [ 26 ]. The first step was reading and familiarising with the collected data. Step two of the data analysis was transcription, which is the process of turning interviews and audio recordings into written information. Coding of the data is step three; the researcher clarifies and highlights words and sentences, according to the participants, which showed a particular similarity. Here, the researcher coded the words precisely as they were written. Step four includes the searching and reviewing of themes. The external co-coder reaffirmed coding to confirm accuracy. Defining and naming of themes is step five, which the researcher used to refine, identify, and capture the midwives’ adjustment to enablers and barriers that were stated by the participants during data collection. It was important for the researcher to further capture the main enablers and barriers, so that there is alignment with the research questions asked. Finally, step six of the thematic data analysis is the writing up. At this point, the researcher concluded, and an article is to be published. Trustworthiness Credibility was achieved through prolonged engagement and member checking. Transferability was facilitated through saturation of data and thick description. The researcher conducted four focus group discussions, and the data collected from the groups were interpreted to make a conclusion and address dependability. The researcher ensured that there were no figments of the inquirer's imagination in the findings, but correctly derived from the collected data, hence addressing confirmability. Furthermore, the researcher-maintained authenticity by portraying the true voice of participants and not altering anything that would be according to the researchers’ assumptions. Ethical considerations The research proposal was first received and approved by the NWU NuMIQ research committee. The study was authorised by the North-West University (NWU) Human Research Ethics Committee (HREC) ethics number (NWU-00191-23-A1). Following all the approvals from (NWU), the researcher sought out permission from the Department of Health, Northern Cape Province. The permission letter from the Department of Health, Northern Cape Province, including another permission letter for the hospital management, was then forwarded to the CEO of the selected rural public hospital, with approval from these gate keepers, another letter was shared with the acting operational manager of the maternity ward of the selected rural public hospital and shared with the staff in the ward. The following ethical principles were maintained: respect, beneficence and non-maleficence, and justice [ 19 ]. FINDINGS Two main themes emerged, namely theme (1) Midwives’ adjustment to enablers of quality maternal healthcare. The two sub-themes identified are: (1.1) passion for midwifery and continuous teamwork, including (1.2) consistent learning and clinical development in midwifery. Theme 2 barriers of quality maternal healthcare, with four sub-themes: (2.1) lack of human resources, (2.2) Lack of material resources, (2.3) inadequate and outdated hospital infrastructure, and (2.4) delayed emergency medical response for maternity care. These two main themes and their sub-themes are clearly outlined in Table 2.2. Table 2 Summary of themes and sub-themes Main themes Sub-themes 1. Midwives’ adjustment to enablers of quality maternal healthcare. 1.1. Passion for midwifery and continuous teamwork. 1.2. Consistent learning and clinical development in midwifery. 2. Barriers to quality maternal healthcare. 2.1. Lack of human resources. 2.2. Lack of material resources. 2.3. Inadequate and outdated hospital infrastructure. 2.4. Delayed emergency medical response for maternity care. Theme 1: Midwives’ adjustment to enablers of quality maternal healthcare Participants highlighted that the significance of combining passion for midwifery, in-service learning, and ongoing clinical development improves the standard of maternal care. By concentrating on these factors, healthcare systems can establish good working conditions that enable maternal healthcare providers to assist mothers and newborns with respect and the highest level of care. Sub-theme 1.1: Passion for midwifery and continuous teamwork Findings revealed that working as a team and being a passionate midwife increase the rate of a successful birth. Furthermore, participants’ passion and compassion for the mother and child were seen to reduce complaints that may arise due to complications of deliveries. This was expressed as follows: “The teamwork of maternity staff, I think, all the midwives love their work more than anything. Even if there's a shortage of staff, they continue to work. Like some people would be referred to other hospitals, but they would always come here because of the wonderful service we provide with the little we have. They come to our hospital because we love our work. Even when we are overloaded, we love our work. We try to do our work as best as possible. By saying I have a passion for midwifery. I am talking about the joy and dedication I have for this profession. Yes, nursing is a calling, yet one needs to be professional and work according to policies, especially because we work with two precious lives”. (P1FG1) Another participant said: “Teamwork, that's the most important thing. Like we in the ward, if we did not have teamwork, I don't know, but this ward will end up with a lot of complicated cases, but with the minimum staff that we have. We try our best to provide quality care, and with the resources we currently have. My colleague mentioned that we support each other at work, and I agree with her. We are like a family, and we really pride ourselves on teamwork. When severe emergencies come in, we all jump in to assist. Because of teamwork, if we don't have teamwork, then I think there will be a lot of errors happening right now, since we are so limited in the ward. So, teamwork will help us a lot. And it also helps prevent burnout at the end of the day. We try to prioritise as much as possible so that the day can run smoothly. The doctors sometimes come in, and they find we are only three nurses in the ward, they do not ask much but do some of our nursing duties so that care can continue”. (P1FG4) And another participant echoed: “We can work without a doctor. Maybe the patient came with eclampsia here. You attend to the patient. After attending to the patient, you call the doctor. If the doctor arrived here, everything would be done for the patient. They can come and refer the patient. Even if we are struggling with deliveries, you can just ask one of our colleagues to come and assist you with the deliveries. If you don't understand anything, just ask. Then you just work hand in hand. You just don't work alone. We ask for help if there is something that you don't know. Even if the machine is here, you don't know how to operate it. We just call one another. Teamwork in our ward is so excellent. Even if there is a shortage of staff and equipment, if she is off. She will come and work. We don't leave one another to suffer”. (P3FG4) Teamwork is vital during childbirth, and all the participants worked together for the success of a healthy mother and child at the end of labour. Sub-theme 1.2: Consistent learning and clinical development in midwifery The importance of participants receiving advanced training at the selected rural public hospital emerged as a sub-theme. It became clear that junior participants don’t want to always be too dependent on senior specialised participants, but also to be able to stand on their own, if only training could be made available to them. This is affirmed through the following expressions: “What enables us to do our work is obvious, we went to school to study, and then we get equipped with all the skills that you need to be competent midwives and then perform at the standard to which you are expected to perform. And that’s something that enables us. You know that there are changes and modifications in midwifery. And then you tend to learn every day about the new developments in the guidelines. I will advocate for training. Well-trained midwives make fewer mistakes and have more knowledge. This is important when it comes to complicated labour. So, by getting continuous training, either as an in-service or by attending school to specialise in advanced midwifery. What I notice about the maternity staff is that they're not resistant. We are not resistant to change and to adopting new information that has been brought into our attention”. (P2FG1) And another participant said: “I am a junior midwife, and that means I will need guidance and advice from my seniors. They assist my other colleagues without complaining. They teach us well so that we can also be independent when they are not here. During emergencies, everyone has their role, and while I am busy with the mother, someone will maybe help with the newborn, and if there are complications, the other midwives will assist and call the doctor. So, we really work harmoniously in our ward; it’s nice to work with this team. Even when we change shifts, the staff of the maternity ward really work well with one another. The other thing I love is that we guide and learn from each other. We refer to policies as much as possible”. (P1FG2) Midwives need to receive advanced training and be experts in their own environment, thereby improving mother and child healthcare services. Further, enablers that benefit patient care are the continuing professional development courses (CPDs), which assist midwives with the changing practices and technologies. Theme 2: Barriers towards quality maternal healthcare Barriers towards quality care were expressed, and four sub-themes emerged as a lack of human and material resources, inadequate hospital infrastructure, including delayed emergency medical transportation response. The participants expressed barriers towards quality maternal care as discussed below: Sub-theme 2.1: Lack of human resources Participants highlighted that patients receive decreased services, which increases the risk of adverse maternal and neonatal outcomes, especially in settings with limited staffing. This also decreased the ability of the participants to render antenatal education and follow-up visits, which are essential components of comprehensive maternal care. The barriers towards quality maternal healthcare were expressed by participants as follows: “Maternity ward is not a ward per se. It is a hospital, so it needs more staff than any other ward in this hospital. Because here, we have a labour room, we have PNC. We have antenatal. So, for the four of us here, you can see we are four here. So, we must take care of the labour room, postnatal and antenatal, and theatre cases, and sometimes sick neonates. And if there is an emergency in the labour room, we're all going to occupy the labour room and leave those other ones alone. So, if each section could have its own staff, labour room four staff, postnatal four staff, ANC four Staff, at least it would enable us to do our work with ease”. (P4FG1) Participants continued and said: “We are short-staffed staffed that one, it's a fact. The reason is that some of the staff members have died. There were no replacements. There are some staff who have resigned and gone on retirement. They will recruit, and interviews will be done, but people will not be hired. I'm sure it's for four years now. We do not have an operational manager. Whoever is senior will take charge. I think a specialised ward like this one is supposed to have an operational manager.” (P3FG1) And another participant said: “Because of the shortage of staff in the ward, we won't be able to provide the patient with the quality care. Sometimes we are running Labour ward postnatal, antenatal, High risk, the outpatients that are coming for high risk, they attend the clinic here and then the patients that are coming from home asking for birth certificates or have lost their road to health card. But so many things, even when we are having a death in the ward, they are coming for the death certificate, so they are queuing outside asking for help. So, if you do have more staff, things will be running smoothly. So, because of a shortage of staff, we don't manage them. Sometimes they are going home without being helped, especially those who are coming from a home which is far from asking for help. (P3FG4) Increasing the number of specialised midwives is urgently needed at the selected rural public hospital. This will decrease the number of midwives who resign and decrease burnout in the workplace. Sub-theme 2.2: Lack of material resources The participants highlighted that they face persistent deficits in basic supplies such as sterile gloves, sutures, birthing beds, personal protective equipment, and neonatal resuscitation kits. These shortages force midwives to improvise or delay care, compromising infection prevention, safe delivery practices, and newborn support, which are foundational to holistic maternity care. The following was verbalised: “There has been no linen for the longest time, but we are expected to admit patients in a clean bed. The equipment has just been bought and is used and not serviced, so maybe that is the problem with the machine that they bought, because the machine will be here, and it will not be serviced. So, the life span of that machine will be shortened, such as the dynamap, sonar, and CTG machines. They must have a maintenance plan, so that the equipment can be serviced on time and last longer”. (P1FG1) And another participant said: “Our machines are so outdated and not enough to be used for this community. If we could have medicines for patients. Our pharmacy does not always have things that we need urgently, and waiting for the tertiary hospital to send them here is a major struggle. We do not have stationery, and the forms that we need to document on are a major challenge as well. The delivery packs, needles, syringes, bed linen and linen savers are a problem to get. There are a lot of machines that are used in other facilities that we do not have. Such as the CPAP that my colleague was talking about just now. Lack of resources, firstly, the BP machine, sonar machine, heating or cooling air conditioners. Some machines are just here, and we just use them even though they are never serviced”. (P2FG4) Another participant said: “There is a lack of equipment, and we have advanced midwives, but sometimes, they can’t use their skills or knowledge because of the lack of equipment. We don’t have delivery packs, the linen is not well cleaned, there are no cleaners, and sometimes the doctors or the ambulance take too long to come. It’s just heavy on us sometimes, we are just working, and it’s a shame, that's why I do not blame some of my colleagues when errors happen. It's emotionally and physically draining. When you get home, you are very tired, have no attention to give at home, and now it’s the family that must suffer”. (P3FG2) The participants at the selected rural public hospital still struggle with basic equipment that they need to perform their duties. It was mentioned that due to this deficit, the patients’ lives may be in danger, which can be simply avoided by the provision of basic resources. Sub-theme 2.3: Inadequate and outdated hospital infrastructure The participants agree that the outdated hospital infrastructure severely hampers their ability to provide holistic patient care by limiting access to safe and functional spaces necessary for quality maternal services. The selected rural public hospital suffers from poorly maintained buildings, overcrowded maternity wards, unreliable water supply, and inconsistent electricity, which disrupt critical aspects of care such as infection control, emergency response, and patient comfort. Inadequate and outdated hospital infrastructure towards quality maternal healthcare was affirmed by participants as follows: “The safety of the patient when taking her to get operated on with this uneven. It's dark outside. What if I fall? This hospital is so old and not work-friendly. The operating theatre is far, and having to go there is a problem. And they need to install more lights outside because even now, you must take blood samples to the lab, and it's dark. So, when you say you are not comfortable walking in the dark, it’s like you don’t want to do your job, because, as already highlighted, there is no hot water, the road to the theatre is worse, some equipment does not even work, and the doctors will complain to me. There is nothing I can do, sadly”. (P1FG2) Another participant added: “If they can build the new hospital, separating the wards. Because in this department that we are working in, the department has all kinds of pregnant women, the labour ward and postnatal ward separately would be nicer. If they can just separate the ward, because in the allocation, you will be seeing there are so many staff in maternity, but because of this large ward, there are not enough. So, if they can separate, there is a postnatal ward, a labour ward, and an antenatal ward. Because when you are working in the postnatal ward now, you are also working in the antenatal ward. If there is something in the labour ward, I must be called again to the labour ward, so that is a lot. So, if they can build a hospital that is separated”. (P3FG3). Another participant said: “The convenience of having an inside theatre when there's an emergency would be helpful. So, in private facilities, they have access to those. Inside the theatre to say now when it's time to cut (C/Section). Sometimes there are not enough doctors to handle an emergency. Maybe the doctor is having another emergency in casualty. Now, the patient must wait, and the patient is compromised. It is not because you don't want to help, but because of the shortage that we have. So generally, in government facilities, there is not usually enough to work with. Sometimes we run out of medication, we run out maybe linen saver, I can say that is another obstruction”. (P6FG4) Participants continued to say: “And the other thing, there is a clinic called a high-risk clinic here in the ward. That high-risk clinic should be run by someone not in the ward because it's a clinic. It's supposed to be out there, not in the ward. So, that high-risk clinic is also taking up our time because for the four of us here, one of us must go and attend the high-risk clinic with the doctor. Whereas the three will be suffering one in the labour rooms, one in the postnatal. And those they had to go to the laboratory, go and fetch the results, take bloods and do the rest of the things”. (P5FG1) The participants highlighted that inadequate sanitation and ventilation expose both patients and midwives to heightened health risks, contributing to staff stress and dissatisfaction among the new mothers and their families. DELAYED EMERGENCY MEDICAL TRANSPORTATION RESPONSE The delayed ambulance responses and the challenges associated with transferring patients to tertiary care facilities during severe obstetric emergencies significantly hinder participants' ability to provide holistic patient care at the selected rural public hospital. Midwives are often forced to assume extended responsibilities beyond their scope while waiting for delayed ambulances, diverting their attention from other patients and weakening the continuity and quality of care. The following vignette was expressed by the participants when addressing delayed emergency medical transportation response. “It’s always a struggle for us to get ambulances if we need to transfer to tertiary hospitals. Because some of the things we cannot do in our hospital. You will call today, and the ambulance will only be here tomorrow. We have only one ambulance for the whole area. And it’s not only maternity that needs an ambulance, this entire hospital, I am sure other wards also request an ambulance”. (P5FG1) Another participant added: “The doctors are staying far from here. So, we must call and wait for a doctor for a long time, as most of them live in town. Because of the distance, they are staying in town, and even the referral hospital is still a problem for us; really, it's too far. The ambulances take a long time they arrive here, and the prognosis is poor. They can't take the baby again or the mother. If we want to refer the baby and mother to the tertiary hospital, there's a problem. So, the ambulance is also a problem, always taking too long to arrive, they drive too far with a compromised mother and child”. (P4FG4) Another participant expressed: “I think, transportation. They should bring ambulances, and they should train the paramedics because some of the paramedics say they cannot take a patient while they are in the preeclamptic phase. They say they are not trained, and it’s not their scope of practice. So, if they can train them, there is a shortage of staff here; they should hire more nurses, more doctors”. (P3FG2) And another participant said: “Other challenges are transport. For example, when we must transfer the patients to the tertiary hospital, there is a delay in EMS because we don’t have enough EMS here to transport the patients to that side. And like in winter, we don’t have air conditioners for the babies, you can feel that in our postnatal ward, it's very cold with newborns. Also, in the labour ward, we deliver the patients in a cold area”. (P2FG3) In time-sensitive situations such as postpartum haemorrhage, obstructed labour, or eclampsia, the absence of prompt emergency transportation exacerbates maternal and neonatal risks, leaving midwives with limited capacity to manage complications within resource-constrained settings. DISCUSSION The study was conducted to explore and describe the perceptions of midwives’ adjustment regarding the enablers and barriers of quality maternal healthcare in a rural selected public hospital in the Northern Cape province of South Africa. From the data collection, two main themes emerged as midwives’ adjustment to enablers of quality maternal healthcare and barriers to quality maternal healthcare. It was clear that the participants are passionate and rely on teamwork to render holistic quality healthcare to the mother and her neonate, though they still face challenges of a shortage of staff, resources, and an outdated hospital infrastructure. The participant's resilience and passion should not be the only determinants of enablers of quality care, but support is still needed to mitigate the daily barriers they face at the selected rural public hospital. Midwives’ adjustment to enablers of quality maternal healthcare Passion for midwifery and continuous teamwork Participants revealed that teamwork plays a vital role, given that the midwives receive support from the hospital management and the government. Regardless of the shortage of human and material resources, the most senior and specialised midwives supported junior midwives by providing them with guidance through in-service learning. The role of specialised midwives becomes important when there are complicated labour cases, while there is a delay with emergency referral to a tertiary hospital or an obstetrician not being available to attend to the complicated labour cases [ 27 ]. The findings revealed that participants in maternity healthcare facilities work better as a team and rely on each other for a successful birth rate. With teamwork, participants can use all their acquired skills in the absence of an obstetrician. It was evident that teamwork is important during childbirth, and many mistakes were avoided when childbearing mothers had at least one birth attendant [ 7 ]. Teamwork was also always linked with a passion for midwifery when it came to mother and child healthcare. Most midwives highlighted that having passion made care easy. Childbearing women became cooperative when they felt respected and in the presence of a skilled midwife [ 9 ]. Consistent learning and clinical development in midwifery The participants further expressed the need to receive support from higher management and the government to provide them with midwifery speciality training. Unfortunately, most participants feel demoralised by the lack of human and material resources. The participants continued to state that knowledge and skills are useless without equipment or support. The participants are eager for consistent learning and clinical development. However, there is still not enough advocacy and financial support to make this happen [ 10 ]. This research aimed to address the need for midwives practising in rural public hospitals to receive speciality and continuous training. The study findings highlight the main challenges faced by the participants in these hospitals and how governments can assist and retain the midwives in rural healthcare facilities. Teamwork, passion, and resilience must not be the only determinants of retention, but consistent in-service learning and training for advanced midwifery is emphasised (3]. Barriers to quality maternal healthcare Lack of human resources The shortage of midwives still leads to avoidable maternal and neonatal deaths [ 27 ]. Closing this gap is essential to reach the Sustainable Development Goals for mother and child health as well as Universal Health Coverage [ 5 ]. The government will continue to see a high increase of resignations amongst midwives who practise in rural maternal healthcare facilities [ 17 ]. The increased workload, shortage of experienced midwives, and delays in recruitment have contributes to the participants often feeling demoralised. The participants are of the same view that the problem is not with the immediate managerial boards but more of a national challenge in rural communities. Midwifery services are essential for promoting safe childbirth and enhancing the health of expectant mothers and newborns [ 20 ]. The shortage of midwives still leads to avoidable maternal and neonatal deaths, as highlighted by the participants. Failure to implement midwives’ adjustment to enablers of maternal healthcare services may have negative implications in rendering quality maternal care. At the selected rural public hospital, midwives are often overwhelmed by high patient volumes and extended work hours due to understaffing, leaving limited time for personalised interactions and comprehensive assessments. The lack of adequate staffing disrupts continuity of care, an essential component of holistic midwifery practice [ 24 ]. Additionally, overburdened participants may experience burnout, moral distress, and compassion fatigue, further undermining their capacity to engage with patients empathetically and comprehensively [ 13 ]. Lack of material resources At this selected rural hospital setting, the participants frequently encounter shortages of essential items such as sterile gloves, antiseptics, sutures, blood pressure monitors, and neonatal resuscitation kits. These deficiencies limit the provision of safe, evidence-based clinical interventions and increase the risk of infection, maternal and neonatal morbidity, and preventable deaths. Without adequate bed linens, privacy screens, or clean birthing environments, the participants are unable to offer mothers a sense of dignity, comfort, or emotional security during one of the most vulnerable moments of their lives. This lack of environmental and material support contributes to maternal anxiety, fear, and dissatisfaction with the birthing experience [ 8 ]. For the participants, working in resource-poor conditions often leads to feelings of frustration, helplessness, and moral distress, especially when they are unable to meet their professional standards of care. These emotional burdens further diminish the quality of interpersonal interactions between the participants and patients. Ultimately, the shortage of material resources severely restricts participants’ capacity to provide quality care. Inadequate and outdated hospital infrastructure The participant explained how the outdated hospital infrastructure at the selected rural public hospital presents significant barriers to their ability to provide quality patient care. They were of the same voice that the facility is characterised by poorly maintained operating theatres, dimly lit corridors, and cramped birthing rooms. Deteriorating maternity wards limit the safety, efficiency, and comfort of the care environment [ 7 ]. Inadequate lighting impairs visibility during critical procedures such as suturing the perineum or neonatal resuscitation, increasing the risk of clinical errors and compromising patient outcomes in the selected rural public hospital theatres. Furthermore, outdated operating theatres often lacked essential equipment, ventilation, or infection control measures, making it difficult for the participants to manage obstetric emergencies with confidence and precision. These physical limitations forced the participants to work in conditions that do not support optimal maternal and newborn care, which undermines their ability to offer both medical and emotional support during labour and delivery. Participants also highlighted that the inconsistent supply of water and electricity in the selected rural public hospital further hinders their capacity to uphold holistic care standards. Frequent power outages disrupt the functioning of essential devices such as foetal monitors, incubators, and sterilisation equipment, while unreliable water supply compromises hygiene, sanitation, and infection prevention protocols. These systemic failures create an unsafe and undignified environment for both patients and healthcare providers, making it difficult for the participants to maintain privacy, cleanliness, and comfort, which are the key components of woman-centred, holistic care. The resulting conditions can heighten anxiety and fear among pregnant women, diminishing their childbirth experience and trust in the health system. For the participants, the emotional and professional toll of delivering care in such constrained environments can lead to burnout and moral distress. Delayed emergency medical response for maternity care Most of the participants were of the same view that delayed ambulance responses during severe obstetric emergencies significantly hindered their work at the selected rural public hospital and obstructed the provision of holistic patient care. In life-threatening situations such as postpartum haemorrhage, obstructed labour, or eclampsia, timely referral to a tertiary hospital is essential for advanced clinical management. However, at the selected rural public hospital setting, ambulance delays are frequent due to poor road infrastructure, limited availability of emergency vehicles, and inadequate coordination within the referral system. Most doctors also live in town, which is approximately a 30-kilometre distance. These delays left the participants with limited options to manage complex emergencies, forcing them to operate beyond their clinical scope of practice in a poorly equipped environment. Furthermore, the inability to transfer critical obstetric emergencies promptly places immense emotional and ethical pressure on the participants, impacting their capacity to deliver holistic, person-centred care. The participants were often left to manage deteriorating clinical conditions without the necessary resources or specialist support, leading to moral distress and a sense of professional helplessness. These conditions can hinder their ability to provide psychological and emotional care to both the patient and her family, especially in situations where outcomes are uncertain or adverse. For mothers and their families, the experience of waiting for delayed emergency transport under stressful conditions can induce anxiety, trauma, and a loss of trust in the healthcare system [ 18 ]. CONCLUSION Midwives in the selected rural public hospital face unique and compounding challenges that necessitate greater support. Rural facilities often operate with critically low staffing levels, resulting in heavy workloads, fragmented care, and minimal time for personalised, woman-centred support [ 17 ]. These shortages are further compounded by limited access to essential resources, outdated infrastructure, and delayed referral systems, all of which compromise the quality and safety of maternal and neonatal care [ 21 ]. Unlike urban hospitals, which typically have higher staff-to-patient ratios, specialised support services, and better-equipped facilities, rural hospitals must deliver the same level of care with significantly fewer resources [ 9 ]. Providing enhanced staffing, targeted training, and improved infrastructure in rural public hospitals is therefore not only a matter of equity but also a critical strategy to reduce preventable maternal and neonatal morbidity and mortality, ensuring that women in remote areas receive the same standard of care as those in urban centres [ 9 ]. The research study was conducted in accordance with the ethical principles of the Declaration of Helsinki, the South African Health Act (Act 61 of 2003) and the Department of health ethics in health research guidelines. Abbreviations ANC: Antenatal Care; BNSc: Bachelor’s degree in nursing science; BP: Blood Pressure; CEO: Chief Executive Officer; CPAP: Continuous Positive Airway Pressure; CPDs: Continuing Professional Development; CTG: Cardiotocograph; DOH: Department of Health; EMS: Emergency Medical Services; FGD: Focused Group Discussion; HIV: Human Immunodeficiency Virus; HREC: Human Research Ethics Committee; ICM: International Conference of Midwives; NGO: Non-governmental Organisation; NHI: National Health Insurance; NuMIQ: Quality in Nursing and Midwifery Research; NWU: North West University; PNC: Postnatal Care; POPI: Protection of Personal Information; SANC: South African Nursing Council; SRC: Scientific Review Committee; Stats SA: Statistics South Africa; WHO: World Health Organisation Declarations Declaration of Helsinki This study adhered to the Declaration of Helsinki to this effect in the ‘Ethics approval and consent was fully given by participants. Ethics approval and consent to participate The NWU, Quality in Nursing and Midwifery (NuMIQ)and the NWU Health Research Ethics Committee approved this study with reference number (NWU-00191-23-A1). After providing all the details of the research study, the written informed consent was obtained from all the participants. All the participants were informed of their right to withdraw from the research study at any time. Privacy and confidentiality of the participants were ensured throughout. The Department of Health (Northern Cape, South Africa). Research reference number: NC_202404_002. This reference number was used for all communication with the research coordinator. The approval was valid for one year after from the date it was issued. The following was noted: The project had to only be conducted at no cost to the Northern Cape Department of Health. The approval had to be limited to the research proposal submitted on the application. There must be no modifications or amendments to the research project. The research unit may monitor this research project at any time. At the completion of this research project, a copy of the final report must be submitted to the research unit. The Northern Cape Department of Health Senior Management must be briefed on the outcome of the study before publishing. Consent for publication Not Applicable Availability of data and materials The corresponding author will make available the data supporting the conclusion of this article upon reasonable request. Competing interests The authors declare no conflict of interests. Funding No financial gain was acquired by the authors from this study. Author details 1 North West University, Mahikeng City, North West Province, South Africa. 2 North West University, Mahikeng City, North West Province, South Africa. 3 North West University, Mahikeng City, North West Province, South Africa. Authors contributions CONCEPTUALISATION, M.B.M, R.M.M., AND S.S.MP; METHODOLOGY, M.B.M, R.M.M., AND S.S.MP; DATA COLLECTION M.B.M.; FORMAL ANALYSIS, M.B.M, R.M.M.; S.S.MP.; RESOURCES, M.B.M; WRITING, M.B.M, WRITING, REVIEW AND EDITING, M.B.M, R.M.M., AND S.S.MP.; SUPERVISION, R.M.M AND S.S.MP.; PROJECT ADMINISTRATION, M.B.M,. ALL AUTHORS HAVE READ AND AGREED TO THE PUBLISHED VERSION OF THE MANUSCRIPT. Authors country of affiliation 1 Motheo Bargio Morena, South Africa, Mahikeng City, North West Province, North West University. 2 Salaminah S. MolokoPhiri, South Africa, Mahikeng City, North West Province, North West University. 3 Rorisang M. Machailo, South Africa, Mahikeng City, North West Province, North West University. Acknowledgements We wish to acknowledge the management and midwives of the selected rural public hospital for the permission and unwavering participation in this study. Data analysis: Prof M. Rakhudu. 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[cited Jan 18 2025] Available from: https://www.health.gov.za/wp-content/uploads/2024/05/NDoH-2024-Health-Research-Guidelines-3rdEdition-v0.1.pdf. Nove A, Friberg IK, De Bernis L, McConville F, Moran AC, Najjemba M, Ten Hoope-Bender P, Tracy S, Homer CS. Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study. Lancet Global Health. 2021;9(1):e24–32. Rikhotso SR. Clinical accompaniment in a rural hospital: student and professional nurses experience (Doctoral dissertation, North-West University). Saralegui-Gainza A, Soto‐Ruiz N, Escalada‐Hernández P, Arregui‐Azagra A, García‐Vivar C, San Martín‐Rodríguez L. Density of nurses and midwives in sub‐Saharan Africa: trends analysis over the period 2004–2016. J Nurs Adm Manag. 2022;30(8):3922–32. Thumm EB, Smith DC, Squires AP, Breedlove G, Meek PM. Burnout of the US midwifery workforce and the role of practice environment. Health Serv Res. 2022;57(2):351–63. Thutse RJ. The Professional Nurses' Perception of Working in Remote Rural Clinics in Limpopo Province. University of South Africa (South Africa); 2006. Polity. 2019. NHI will only see more moms and babies die. Polity Newsletter , Issue 1 . https://www.polity.org.za/article/nhi-will-only-see-more-moms-and-babies-die-2019-11-04 Date of access: 11 Jun. 2022. Ahmed SK, Mohammed RA, Nashwan AJ, Ibrahim RH, Abdalla AQ, Ameen BMM, Khdhir RM. Using thematic analysis in qualitative research. J Med Surg Public Health. 2025;6:100198. https://doi.org/10.1016/j.glmedi.2025.100198 . Byrne AL, Baldwin A, Harvey C. Whose centre is it anyway? Defining person-centred care in nursing: An integrative review. PLoS ONE. 2020;15(3):e0229923. https://doi.org/10.1371/journal.pone.0229923 . Aksünger N, De Sanctis T, Waiyaiya E, van Doeveren R, van der Graaf M, Janssens W. 2022. What prevents pregnant women from adhering to the continuum of maternal care? Evidence on interrelated mechanisms from a cohort study in Kenya. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1Interviewschedule.docx Additional file 1: Interview schedule Supplementaryfile2DOHNorthernCapePermissionLetter.pdf Additional file 2: DoH Northern Cape Permission Letter Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 22 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers invited by journal 21 Jan, 2026 Editor invited by journal 30 Dec, 2025 Editor assigned by journal 23 Dec, 2025 Submission checks completed at journal 22 Dec, 2025 First submitted to journal 22 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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13:40:56","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":74244,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 2: DoH Northern Cape Permission Letter\u003c/p\u003e","description":"","filename":"Supplementaryfile2DOHNorthernCapePermissionLetter.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8243812/v1/de4e7195f7f4051d485fb3f2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Midwives’ perceptions of enablers and barriers of quality maternal healthcare in a rural public hospital in the Northern Cape Province","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe shortage of trained and experienced midwives in rural public hospitals remains a concern in the world [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Governments need to implement strategies for the training and retention of midwives in rural healthcare facilities that provide maternal and childcare services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Literature suggests that in rural healthcare facilities, most midwives are complaining of burnout, shortage of human and physical resources, including poor working conditions due to old infrastructure [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Research conducted in the African countries and Southeast Asia highlighted that midwives are working in environments that lack essential resources and equipment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Meanwhile, the increased workloads, shortage of midwives and compromised quality of neonatal care in rural hospitals of the Limpopo province in South Africa are of concern [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] highlighted that, in the Northern Cape Province of South Africa, there has been challenges in the local rural hospital and that more moms and babies would not survive due to the old hospital infrastructures posing a direct risk to the lives of patients and staff. However, in rural South African settings, the severe shortage of midwives results in high workloads, fragmented care, and limited time to provide individualised, woman-centred support.\u003c/p\u003e \u003cp\u003eBoth teamwork and passion for midwifery ensure that midwives provide holistic quality care to mother and child from conception until birth [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A key component of midwifery practice in South Africa is passion and teamwork. Research across the world has depicted that teamwork and passion are the drivers of holistic and quality care for mother and child in maternal healthcare. However, these should not be the only determiners of retention of staff in the maternal health environment. Advanced training for midwives and good working conditions needs to be urgently implemented in rural public hospitals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The World Health Organisation (WHO) has reported that midwifery profession has many challenges, which includes lack of equipment, treatment materials and patients of limited financial means face disadvantages because of these challenges. These challenges further put more burden on the already overwhelmed midwives. Despite these challenges, young people still pursue nursing as a career, and do not do it with a good heart but prioritise money more, which is not the way to become a good midwife.\u003c/p\u003e \u003cp\u003eTherefore, improvement and advocacy in rural public hospitals where midwives practice need attention. The provision of staff, resources, and advanced training for midwives needs to be urgently attended to. Literature affirms that in-service education, continuing professional development, and advanced training for midwives who provide maternal healthcare in rural public hospitals have proven to enable midwives to give quality care to women and their newborn babies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Well-trained midwives can respond immediately to complicated births; hence, training these midwives is vital. Addressing human and material resources scarcity in underserved maternal healthcare facilities can improve maternal and neonatal health outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Maternal and newborn health greatly depends on the dedication and collaboration of midwives. Their dedication and cooperative efforts continue to move midwifery practice forward, greatly enhancing the health of mothers and children nationwide.\u003c/p\u003e \u003cp\u003eThe delivery of holistic patient care in rural hospitals is significantly compromised by structural health system challenges, including the shortage of midwives, inadequate material resources, outdated hospital infrastructure, and delayed emergency response systems. Holistic care in midwifery involves a comprehensive approach that integrates physical, emotional, social, and psychological support for women and their newborns throughout the perinatal period. This workforce gap not only compromises routine maternity care but also impairs the management of obstetric emergencies, where coordinated team responses and efficient referral systems are vital.\u003c/p\u003e \u003cp\u003eThe burden placed on overextended midwives is further exacerbated by the lack of essential supplies and equipment, such as oxygen cylinders, sutures, transport trolleys, and neonatal resuscitation tools, which are frequently unavailable or poorly maintained in rural facilities. These resource gaps obstruct safe emergency stabilisation before transfer and delay necessary interventions during critical periods, placing both maternal and neonatal lives at risk.\u003c/p\u003e \u003cp\u003eThe outdated hospital infrastructure, including unreliable electricity, poor sanitation, and inadequate road access, plays a central role in delaying emergency responses and limiting the functionality of referral systems in rural areas. Many rural hospitals lack operational emergency rooms, efficient communication systems, or functional ambulance bays, all of which are essential for prompt and effective emergency care coordination. The result is frequent delays in ambulance response and prolonged transfer times to tertiary care centres. This delay is detrimental during life-threatening conditions such as eclampsia, uterine rupture, or severe haemorrhage, where time-sensitive interventions are critical. Midwives are left to manage emergencies with limited capacity, leading to emotional exhaustion, moral distress, and professional dissatisfaction.\u003c/p\u003e \u003cp\u003eMoreover, patients and families experience heightened anxiety, fear, and distrust toward the health system, undermining their overall experience of care. These factors collectively hinder the midwives\u0026rsquo; ability to provide holistic, respectful, and safe maternity care, highlighting the urgent need for systemic investment in rural healthcare infrastructure, workforce development, and emergency response mechanisms.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eStudy design\u003c/p\u003e \u003cp\u003eA qualitative, explorative, descriptive and contextual design was followed. This allowed researchers to compare verbal data with observed data and draw conclusions from the midwives\u0026rsquo; adjustment enablers and barriers stated by midwives in selected rural public hospitals [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudy population and sampling\u003c/p\u003e \u003cp\u003eThe targeted population included all professional nurses who are maternal healthcare workers at the selected rural public hospital, with an experience of more than 12 months as a midwife. A non-probability purposive sampling technique was adopted as it is related to the experiential phenomenon of the research study. The sample included 23 midwives and accoucheurs, who both consented to participate in the study and a total of four focused groups.\u003c/p\u003e \u003cp\u003eStudy setting\u003c/p\u003e \u003cp\u003eThe study was conducted at the selected rural public hospital of the Northern Cape Province of South Africa. The hospital has one maternity ward, which provides antenatal, labour, and postnatal services. Day patients and high-risk clinics use the same ward. The ward has a total bed occupancy of thirty-five (35), which are: eleven (11) antenatal beds, eighteen (18) postnatal beds, and six (06) delivery beds. The surrounding clinics refer all patients who are in labour to the selected rural public hospital.\u003c/p\u003e \u003cp\u003eSelection criteria\u003c/p\u003e \u003cp\u003eOnly professional nurses who are maternal healthcare workers and employed in the maternity ward for more than one year at the selected rural public hospital participated in the study, so that they could share correct midwives\u0026rsquo; adjustment to enablers and barriers while practising at the hospital. All practising professional nurses who are maternal healthcare workers were registered with the South African Nursing Council (SANC) and have a current practising licence. Both men and women who are professional nurses and work as maternal healthcare providers at the selected public rural hospital were included in the study.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of midwives\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualifications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth facility\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Bachelor\u0026rsquo;s degree in nursing science (BNSc).\u003c/p\u003e \u003cp\u003e-Advanced diploma in midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Bachelor\u0026rsquo;s degree in nursing science (BNSc).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing.\u003c/p\u003e \u003cp\u003e-Advanced diploma in midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Bachelor\u0026rsquo;s degree in nursing science (BNSc)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma in Nursing with Midwifery.\u003c/p\u003e \u003cp\u003e-Advanced Diploma in midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Bachelor\u0026rsquo;s degree in nursing science\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003cp\u003e-Advanced Diploma in midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Bachelor\u0026rsquo;s degree in nursing science (BNSc).\u003c/p\u003e \u003cp\u003e-Advanced midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Bachelor\u0026rsquo;s degree in nursing science (BNSc).\u003c/p\u003e \u003cp\u003e-Advanced midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Bachelor\u0026rsquo;s degree in nursing (BNSc).\u003c/p\u003e \u003cp\u003e-Advanced midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with Midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with Midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-Diploma in Nursing with midwifery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternity ward of the selected hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eFor the study the researchers developed their own interview schedule, and the research assistant distributed the invitation and consent forms after all the permissions had been received. The focus group interviews were conducted in a secluded room inside the maternity ward. A voice recorder and field notes were used during the focus group discussions with permission from the participants. Data was collected from 23 participants, all maternal healthcare workers practising at the selected rural public hospital for more than one year. Four focus group discussions (FGD) were conducted with 5 to 6 participants per group. Both male and female participants were included, within the age range of 24 to 60 years. All the participants hold the following qualifications: Bachelor\u0026rsquo;s degree in nursing, a Comprehensive Diploma in Nursing, a diploma in nursing and midwifery, including an advanced Diploma in midwifery as approved by the South African Nursing Council.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSUPPLEMENTARY FILE 1: DATA COLLECTION TOOL/INTERVIEW SCHEDULE\u003c/h2\u003e \u003cp\u003e \u003cb\u003eAll participants will be asked the following main questions and other questions will be directed by the participants\u0026rsquo; response.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWhat are the perceptions of midwives regarding the enablers of quality maternal healthcare in a rural public hospital in the Northern Cape Province?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhat are the perceptions of midwives regarding the barriers towards quality maternal healthcare in a rural public hospital in the Northern Cape Province?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe following questions will be used as follow-up questions:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWhat is the quality of maternal healthcare at this hospital?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePlease tell me more about the barriers you have experienced in delivering quality maternal healthcare as a midwife in this hospital.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAre the facilitators or enablers that you have experienced that help you deliver quality maternal healthcare? If so, can you tell me more?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTell me more about your experiences as a midwife in this hospital.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDo you have any recommendations for midwives regarding delivery of quality maternal healthcare in this hospital?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThematic data analysis was used, which includes six steps [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The first step was reading and familiarising with the collected data. Step two of the data analysis was transcription, which is the process of turning interviews and audio recordings into written information. Coding of the data is step three; the researcher clarifies and highlights words and sentences, according to the participants, which showed a particular similarity. Here, the researcher coded the words precisely as they were written. Step four includes the searching and reviewing of themes. The external co-coder reaffirmed coding to confirm accuracy. Defining and naming of themes is step five, which the researcher used to refine, identify, and capture the midwives\u0026rsquo; adjustment to enablers and barriers that were stated by the participants during data collection. It was important for the researcher to further capture the main enablers and barriers, so that there is alignment with the research questions asked. Finally, step six of the thematic data analysis is the writing up. At this point, the researcher concluded, and an article is to be published.\u003c/p\u003e \u003cp\u003eTrustworthiness\u003c/p\u003e \u003cp\u003eCredibility was achieved through prolonged engagement and member checking. Transferability was facilitated through saturation of data and thick description. The researcher conducted four focus group discussions, and the data collected from the groups were interpreted to make a conclusion and address dependability. The researcher ensured that there were no figments of the inquirer's imagination in the findings, but correctly derived from the collected data, hence addressing confirmability. Furthermore, the researcher-maintained authenticity by portraying the true voice of participants and not altering anything that would be according to the researchers\u0026rsquo; assumptions.\u003c/p\u003e \u003cp\u003eEthical considerations\u003c/p\u003e \u003cp\u003eThe research proposal was first received and approved by the NWU NuMIQ research committee. The study was authorised by the North-West University (NWU) Human Research Ethics Committee (HREC) ethics number (NWU-00191-23-A1). Following all the approvals from (NWU), the researcher sought out permission from the Department of Health, Northern Cape Province. The permission letter from the Department of Health, Northern Cape Province, including another permission letter for the hospital management, was then forwarded to the CEO of the selected rural public hospital, with approval from these gate keepers, another letter was shared with the acting operational manager of the maternity ward of the selected rural public hospital and shared with the staff in the ward. The following ethical principles were maintained: respect, beneficence and non-maleficence, and justice [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"FINDINGS","content":"\u003cp\u003eTwo main themes emerged, namely theme (1) Midwives\u0026rsquo; adjustment to enablers of quality maternal healthcare. The two sub-themes identified are: (1.1) passion for midwifery and continuous teamwork, including (1.2) consistent learning and clinical development in midwifery. Theme 2 barriers of quality maternal healthcare, with four sub-themes: (2.1) lack of human resources, (2.2) Lack of material resources, (2.3) inadequate and outdated hospital infrastructure, and (2.4) delayed emergency medical response for maternity care. These two main themes and their sub-themes are clearly outlined in Table\u0026nbsp;2.2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of themes and sub-themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Midwives\u0026rsquo; adjustment to enablers of quality maternal healthcare.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1. Passion for midwifery and continuous teamwork.\u003c/p\u003e \u003cp\u003e1.2. Consistent learning and clinical development in midwifery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Barriers to quality maternal healthcare.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1. Lack of human resources.\u003c/p\u003e \u003cp\u003e2.2. Lack of material resources.\u003c/p\u003e \u003cp\u003e2.3. Inadequate and outdated hospital infrastructure.\u003c/p\u003e \u003cp\u003e2.4. Delayed emergency medical response for maternity care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTheme 1: Midwives\u0026rsquo; adjustment to enablers of quality maternal healthcare\u003c/p\u003e \u003cp\u003eParticipants highlighted that the significance of combining passion for midwifery, in-service learning, and ongoing clinical development improves the standard of maternal care. By concentrating on these factors, healthcare systems can establish good working conditions that enable maternal healthcare providers to assist mothers and newborns with respect and the highest level of care.\u003c/p\u003e\n\u003ch3\u003eSub-theme 1.1: Passion for midwifery and continuous teamwork\u003c/h3\u003e\n\u003cp\u003eFindings revealed that working as a team and being a passionate midwife increase the rate of a successful birth. Furthermore, participants\u0026rsquo; passion and compassion for the mother and child were seen to reduce complaints that may arise due to complications of deliveries. This was expressed as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The teamwork of maternity staff, I think, all the midwives love their work more than anything. Even if there's a shortage of staff, they continue to work. Like some people would be referred to other hospitals, but they would always come here because of the wonderful service we provide with the little we have. They come to our hospital because we love our work. Even when we are overloaded, we love our work. We try to do our work as best as possible. By saying I have a passion for midwifery. I am talking about the joy and dedication I have for this profession. Yes, nursing is a calling, yet one needs to be professional and work according to policies, especially because we work with two precious lives\u0026rdquo;.\u003c/em\u003e (P1FG1)\u003c/p\u003e \u003cp\u003eAnother participant said:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Teamwork, that's the most important thing. Like we in the ward, if we did not have teamwork, I don't know, but this ward will end up with a lot of complicated cases, but with the minimum staff that we have. We try our best to provide quality care, and with the resources we currently have. My colleague mentioned that we support each other at work, and I agree with her. We are like a family, and we really pride ourselves on teamwork. When severe emergencies come in, we all jump in to assist. Because of teamwork, if we don't have teamwork, then I think there will be a lot of errors happening right now, since we are so limited in the ward. So, teamwork will help us a lot. And it also helps prevent burnout at the end of the day. We try to prioritise as much as possible so that the day can run smoothly. The doctors sometimes come in, and they find we are only three nurses in the ward, they do not ask much but do some of our nursing duties so that care can continue\u0026rdquo;.\u003c/em\u003e (P1FG4)\u003c/p\u003e \u003cp\u003eAnd another participant echoed:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We can work without a doctor. Maybe the patient came with eclampsia here. You attend to the patient. After attending to the patient, you call the doctor. If the doctor arrived here, everything would be done for the patient. They can come and refer the patient. Even if we are struggling with deliveries, you can just ask one of our colleagues to come and assist you with the deliveries. If you don't understand anything, just ask. Then you just work hand in hand. You just don't work alone. We ask for help if there is something that you don't know. Even if the machine is here, you don't know how to operate it. We just call one another. Teamwork in our ward is so excellent. Even if there is a shortage of staff and equipment, if she is off. She will come and work. We don't leave one another to suffer\u0026rdquo;.\u003c/em\u003e (P3FG4)\u003c/p\u003e \u003cp\u003eTeamwork is vital during childbirth, and all the participants worked together for the success of a healthy mother and child at the end of labour.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 1.2: Consistent learning and clinical development in midwifery\u003c/h2\u003e \u003cp\u003eThe importance of participants receiving advanced training at the selected rural public hospital emerged as a sub-theme. It became clear that junior participants don\u0026rsquo;t want to always be too dependent on senior specialised participants, but also to be able to stand on their own, if only training could be made available to them. This is affirmed through the following expressions:\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;What enables us to do our work is obvious, we went to school to study, and then we get equipped with all the skills that you need to be competent midwives and then perform at the standard to which you are expected to perform. And that\u0026rsquo;s something that enables us. You know that there are changes and modifications in midwifery. And then you tend to learn every day about the new developments in the guidelines. I will advocate for training. Well-trained midwives make fewer mistakes and have more knowledge. This is important when it comes to complicated labour. So, by getting continuous training, either as an in-service or by attending school to specialise in advanced midwifery. What I notice about the maternity staff is that they're not resistant. We are not resistant to change and to adopting new information that has been brought into our attention\u0026rdquo;.\u003c/em\u003e (P2FG1)\u003c/p\u003e \u003cp\u003eAnd another participant said:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I am a junior midwife, and that means I will need guidance and advice from my seniors. They assist my other colleagues without complaining. They teach us well so that we can also be independent when they are not here. During emergencies, everyone has their role, and while I am busy with the mother, someone will maybe help with the newborn, and if there are complications, the other midwives will assist and call the doctor. So, we really work harmoniously in our ward; it\u0026rsquo;s nice to work with this team. Even when we change shifts, the staff of the maternity ward really work well with one another. The other thing I love is that we guide and learn from each other. We refer to policies as much as possible\u0026rdquo;.\u003c/em\u003e (P1FG2)\u003c/p\u003e \u003cp\u003eMidwives need to receive advanced training and be experts in their own environment, thereby improving mother and child healthcare services. Further, enablers that benefit patient care are the continuing professional development courses (CPDs), which assist midwives with the changing practices and technologies.\u003c/p\u003e \u003cp\u003eTheme 2: Barriers towards quality maternal healthcare\u003c/p\u003e \u003cp\u003eBarriers towards quality care were expressed, and four sub-themes emerged as a lack of human and material resources, inadequate hospital infrastructure, including delayed emergency medical transportation response. The participants expressed barriers towards quality maternal care as discussed below:\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSub-theme 2.1: Lack of human resources\u003c/h3\u003e\n\u003cp\u003eParticipants highlighted that patients receive decreased services, which increases the risk of adverse maternal and neonatal outcomes, especially in settings with limited staffing. This also decreased the ability of the participants to render antenatal education and follow-up visits, which are essential components of comprehensive maternal care.\u003c/p\u003e \u003cp\u003eThe barriers towards quality maternal healthcare were expressed by participants as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Maternity ward is not a ward per se. It is a hospital, so it needs more staff than any other ward in this hospital. Because here, we have a labour room, we have PNC. We have antenatal. So, for the four of us here, you can see we are four here. So, we must take care of the labour room, postnatal and antenatal, and theatre cases, and sometimes sick neonates. And if there is an emergency in the labour room, we're all going to occupy the labour room and leave those other ones alone. So, if each section could have its own staff, labour room four staff, postnatal four staff, ANC four Staff, at least it would enable us to do our work with ease\u0026rdquo;.\u003c/em\u003e (P4FG1)\u003c/p\u003e \u003cp\u003eParticipants continued and said:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We are short-staffed staffed that one, it's a fact. The reason is that some of the staff members have died. There were no replacements. There are some staff who have resigned and gone on retirement. They will recruit, and interviews will be done, but people will not be hired. I'm sure it's for four years now. We do not have an operational manager. Whoever is senior will take charge. I think a specialised ward like this one is supposed to have an operational manager.\u0026rdquo;\u003c/em\u003e (P3FG1)\u003c/p\u003e \u003cp\u003eAnd another participant said:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because of the shortage of staff in the ward, we won't be able to provide the patient with the quality care. Sometimes we are running Labour ward postnatal, antenatal, High risk, the outpatients that are coming for high risk, they attend the clinic here and then the patients that are coming from home asking for birth certificates or have lost their road to health card. But so many things, even when we are having a death in the ward, they are coming for the death certificate, so they are queuing outside asking for help. So, if you do have more staff, things will be running smoothly. So, because of a shortage of staff, we don't manage them. Sometimes they are going home without being helped, especially those who are coming from a home which is far from asking for help.\u003c/em\u003e (P3FG4)\u003c/p\u003e \u003cp\u003eIncreasing the number of specialised midwives is urgently needed at the selected rural public hospital. This will decrease the number of midwives who resign and decrease burnout in the workplace.\u003c/p\u003e\n\u003ch3\u003eSub-theme 2.2: Lack of material resources\u003c/h3\u003e\n\u003cp\u003eThe participants highlighted that they face persistent deficits in basic supplies such as sterile gloves, sutures, birthing beds, personal protective equipment, and neonatal resuscitation kits. These shortages force midwives to improvise or delay care, compromising infection prevention, safe delivery practices, and newborn support, which are foundational to holistic maternity care. The following was verbalised:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There has been no linen for the longest time, but we are expected to admit patients in a clean bed. The equipment has just been bought and is used and not serviced, so maybe that is the problem with the machine that they bought, because the machine will be here, and it will not be serviced. So, the life span of that machine will be shortened, such as the dynamap, sonar, and CTG machines. They must have a maintenance plan, so that the equipment can be serviced on time and last longer\u0026rdquo;.\u003c/em\u003e (P1FG1)\u003c/p\u003e \u003cp\u003eAnd another participant said:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Our machines are so outdated and not enough to be used for this community. If we could have medicines for patients. Our pharmacy does not always have things that we need urgently, and waiting for the tertiary hospital to send them here is a major struggle. We do not have stationery, and the forms that we need to document on are a major challenge as well. The delivery packs, needles, syringes, bed linen and linen savers are a problem to get. There are a lot of machines that are used in other facilities that we do not have. Such as the CPAP that my colleague was talking about just now. Lack of resources, firstly, the BP machine, sonar machine, heating or cooling air conditioners. Some machines are just here, and we just use them even though they are never serviced\u0026rdquo;.\u003c/em\u003e (P2FG4)\u003c/p\u003e \u003cp\u003eAnother participant said:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is a lack of equipment, and we have advanced midwives, but sometimes, they can\u0026rsquo;t use their skills or knowledge because of the lack of equipment. We don\u0026rsquo;t have delivery packs, the linen is not well cleaned, there are no cleaners, and sometimes the doctors or the ambulance take too long to come. It\u0026rsquo;s just heavy on us sometimes, we are just working, and it\u0026rsquo;s a shame, that's why I do not blame some of my colleagues when errors happen. It's emotionally and physically draining. When you get home, you are very tired, have no attention to give at home, and now it\u0026rsquo;s the family that must suffer\u0026rdquo;.\u003c/em\u003e (P3FG2)\u003c/p\u003e \u003cp\u003eThe participants at the selected rural public hospital still struggle with basic equipment that they need to perform their duties. It was mentioned that due to this deficit, the patients\u0026rsquo; lives may be in danger, which can be simply avoided by the provision of basic resources.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSub-theme 2.3: Inadequate and outdated hospital infrastructure\u003c/h2\u003e \u003cp\u003eThe participants agree that the outdated hospital infrastructure severely hampers their ability to provide holistic patient care by limiting access to safe and functional spaces necessary for quality maternal services. The selected rural public hospital suffers from poorly maintained buildings, overcrowded maternity wards, unreliable water supply, and inconsistent electricity, which disrupt critical aspects of care such as infection control, emergency response, and patient comfort.\u003c/p\u003e \u003cp\u003eInadequate and outdated hospital infrastructure towards quality maternal healthcare was affirmed by participants as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The safety of the patient when taking her to get operated on with this uneven. It's dark outside. What if I fall? This hospital is so old and not work-friendly. The operating theatre is far, and having to go there is a problem. And they need to install more lights outside because even now, you must take blood samples to the lab, and it's dark. So, when you say you are not comfortable walking in the dark, it\u0026rsquo;s like you don\u0026rsquo;t want to do your job, because, as already highlighted, there is no hot water, the road to the theatre is worse, some equipment does not even work, and the doctors will complain to me. There is nothing I can do, sadly\u0026rdquo;.\u003c/em\u003e (P1FG2)\u003c/p\u003e \u003cp\u003eAnother participant added:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If they can build the new hospital, separating the wards. Because in this department that we are working in, the department has all kinds of pregnant women, the labour ward and postnatal ward separately would be nicer. If they can just separate the ward, because in the allocation, you will be seeing there are so many staff in maternity, but because of this large ward, there are not enough. So, if they can separate, there is a postnatal ward, a labour ward, and an antenatal ward. Because when you are working in the postnatal ward now, you are also working in the antenatal ward. If there is something in the labour ward, I must be called again to the labour ward, so that is a lot. So, if they can build a hospital that is separated\u0026rdquo;.\u003c/em\u003e (P3FG3).\u003c/p\u003e \u003cp\u003eAnother participant said:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The convenience of having an inside theatre when there's an emergency would be helpful. So, in private facilities, they have access to those. Inside the theatre to say now when it's time to cut (C/Section). Sometimes there are not enough doctors to handle an emergency. Maybe the doctor is having another emergency in casualty. Now, the patient must wait, and the patient is compromised. It is not because you don't want to help, but because of the shortage that we have. So generally, in government facilities, there is not usually enough to work with. Sometimes we run out of medication, we run out maybe linen saver, I can say that is another obstruction\u0026rdquo;.\u003c/em\u003e (P6FG4)\u003c/p\u003e \u003cp\u003eParticipants continued to say:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;And the other thing, there is a clinic called a high-risk clinic here in the ward. That high-risk clinic should be run by someone not in the ward because it's a clinic. It's supposed to be out there, not in the ward. So, that high-risk clinic is also taking up our time because for the four of us here, one of us must go and attend the high-risk clinic with the doctor. Whereas the three will be suffering one in the labour rooms, one in the postnatal. And those they had to go to the laboratory, go and fetch the results, take bloods and do the rest of the things\u0026rdquo;. (P5FG1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe participants highlighted that inadequate sanitation and ventilation expose both patients and midwives to heightened health risks, contributing to staff stress and dissatisfaction among the new mothers and their families.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDELAYED EMERGENCY MEDICAL TRANSPORTATION RESPONSE\u003c/h2\u003e \u003cp\u003eThe delayed ambulance responses and the challenges associated with transferring patients to tertiary care facilities during severe obstetric emergencies significantly hinder participants' ability to provide holistic patient care at the selected rural public hospital. Midwives are often forced to assume extended responsibilities beyond their scope while waiting for delayed ambulances, diverting their attention from other patients and weakening the continuity and quality of care.\u003c/p\u003e \u003cp\u003eThe following vignette was expressed by the participants when addressing delayed emergency medical transportation response.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s always a struggle for us to get ambulances if we need to transfer to tertiary hospitals. Because some of the things we cannot do in our hospital. You will call today, and the ambulance will only be here tomorrow. We have only one ambulance for the whole area. And it\u0026rsquo;s not only maternity that needs an ambulance, this entire hospital, I am sure other wards also request an ambulance\u0026rdquo;.\u003c/em\u003e (P5FG1)\u003c/p\u003e \u003cp\u003eAnother participant added:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The doctors are staying far from here. So, we must call and wait for a doctor for a long time, as most of them live in town. Because of the distance, they are staying in town, and even the referral hospital is still a problem for us; really, it's too far. The ambulances take a long time they arrive here, and the prognosis is poor. They can't take the baby again or the mother. If we want to refer the baby and mother to the tertiary hospital, there's a problem. So, the ambulance is also a problem, always taking too long to arrive, they drive too far with a compromised mother and child\u0026rdquo;.\u003c/em\u003e (P4FG4)\u003c/p\u003e \u003cp\u003eAnother participant expressed:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think, transportation. They should bring ambulances, and they should train the paramedics because some of the paramedics say they cannot take a patient while they are in the preeclamptic phase. They say they are not trained, and it\u0026rsquo;s not their scope of practice. So, if they can train them, there is a shortage of staff here; they should hire more nurses, more doctors\u0026rdquo;.\u003c/em\u003e (P3FG2)\u003c/p\u003e \u003cp\u003eAnd another participant said:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Other challenges are transport. For example, when we must transfer the patients to the tertiary hospital, there is a delay in EMS because we don\u0026rsquo;t have enough EMS here to transport the patients to that side. And like in winter, we don\u0026rsquo;t have air conditioners for the babies, you can feel that in our postnatal ward, it's very cold with newborns. Also, in the labour ward, we deliver the patients in a cold area\u0026rdquo;.\u003c/em\u003e (P2FG3)\u003c/p\u003e \u003cp\u003eIn time-sensitive situations such as postpartum haemorrhage, obstructed labour, or eclampsia, the absence of prompt emergency transportation exacerbates maternal and neonatal risks, leaving midwives with limited capacity to manage complications within resource-constrained settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe study was conducted to explore and describe the perceptions of midwives\u0026rsquo; adjustment regarding the enablers and barriers of quality maternal healthcare in a rural selected public hospital in the Northern Cape province of South Africa. From the data collection, two main themes emerged as midwives\u0026rsquo; adjustment to enablers of quality maternal healthcare and barriers to quality maternal healthcare. It was clear that the participants are passionate and rely on teamwork to render holistic quality healthcare to the mother and her neonate, though they still face challenges of a shortage of staff, resources, and an outdated hospital infrastructure. The participant's resilience and passion should not be the only determinants of enablers of quality care, but support is still needed to mitigate the daily barriers they face at the selected rural public hospital.\u003c/p\u003e \u003cp\u003eMidwives\u0026rsquo; adjustment to enablers of quality maternal healthcare\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePassion for midwifery and continuous teamwork\u003c/h2\u003e \u003cp\u003eParticipants revealed that teamwork plays a vital role, given that the midwives receive support from the hospital management and the government. Regardless of the shortage of human and material resources, the most senior and specialised midwives supported junior midwives by providing them with guidance through in-service learning. The role of specialised midwives becomes important when there are complicated labour cases, while there is a delay with emergency referral to a tertiary hospital or an obstetrician not being available to attend to the complicated labour cases [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The findings revealed that participants in maternity healthcare facilities work better as a team and rely on each other for a successful birth rate. With teamwork, participants can use all their acquired skills in the absence of an obstetrician. It was evident that teamwork is important during childbirth, and many mistakes were avoided when childbearing mothers had at least one birth attendant [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Teamwork was also always linked with a passion for midwifery when it came to mother and child healthcare. Most midwives highlighted that having passion made care easy. Childbearing women became cooperative when they felt respected and in the presence of a skilled midwife [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eConsistent learning and clinical development in midwifery\u003c/h2\u003e \u003cp\u003eThe participants further expressed the need to receive support from higher management and the government to provide them with midwifery speciality training. Unfortunately, most participants feel demoralised by the lack of human and material resources. The participants continued to state that knowledge and skills are useless without equipment or support. The participants are eager for consistent learning and clinical development. However, there is still not enough advocacy and financial support to make this happen [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This research aimed to address the need for midwives practising in rural public hospitals to receive speciality and continuous training. The study findings highlight the main challenges faced by the participants in these hospitals and how governments can assist and retain the midwives in rural healthcare facilities. Teamwork, passion, and resilience must not be the only determinants of retention, but consistent in-service learning and training for advanced midwifery is emphasised (3].\u003c/p\u003e \u003cp\u003eBarriers to quality maternal healthcare\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLack of human resources\u003c/h2\u003e \u003cp\u003eThe shortage of midwives still leads to avoidable maternal and neonatal deaths [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Closing this gap is essential to reach the Sustainable Development Goals for mother and child health as well as Universal Health Coverage [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The government will continue to see a high increase of resignations amongst midwives who practise in rural maternal healthcare facilities [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The increased workload, shortage of experienced midwives, and delays in recruitment have contributes to the participants often feeling demoralised. The participants are of the same view that the problem is not with the immediate managerial boards but more of a national challenge in rural communities. Midwifery services are essential for promoting safe childbirth and enhancing the health of expectant mothers and newborns [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The shortage of midwives still leads to avoidable maternal and neonatal deaths, as highlighted by the participants. Failure to implement midwives\u0026rsquo; adjustment to enablers of maternal healthcare services may have negative implications in rendering quality maternal care. At the selected rural public hospital, midwives are often overwhelmed by high patient volumes and extended work hours due to understaffing, leaving limited time for personalised interactions and comprehensive assessments. The lack of adequate staffing disrupts continuity of care, an essential component of holistic midwifery practice [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, overburdened participants may experience burnout, moral distress, and compassion fatigue, further undermining their capacity to engage with patients empathetically and comprehensively [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLack of material resources\u003c/h2\u003e \u003cp\u003eAt this selected rural hospital setting, the participants frequently encounter shortages of essential items such as sterile gloves, antiseptics, sutures, blood pressure monitors, and neonatal resuscitation kits. These deficiencies limit the provision of safe, evidence-based clinical interventions and increase the risk of infection, maternal and neonatal morbidity, and preventable deaths. Without adequate bed linens, privacy screens, or clean birthing environments, the participants are unable to offer mothers a sense of dignity, comfort, or emotional security during one of the most vulnerable moments of their lives. This lack of environmental and material support contributes to maternal anxiety, fear, and dissatisfaction with the birthing experience [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. For the participants, working in resource-poor conditions often leads to feelings of frustration, helplessness, and moral distress, especially when they are unable to meet their professional standards of care. These emotional burdens further diminish the quality of interpersonal interactions between the participants and patients. Ultimately, the shortage of material resources severely restricts participants\u0026rsquo; capacity to provide quality care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eInadequate and outdated hospital infrastructure\u003c/h2\u003e \u003cp\u003eThe participant explained how the outdated hospital infrastructure at the selected rural public hospital presents significant barriers to their ability to provide quality patient care. They were of the same voice that the facility is characterised by poorly maintained operating theatres, dimly lit corridors, and cramped birthing rooms. Deteriorating maternity wards limit the safety, efficiency, and comfort of the care environment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Inadequate lighting impairs visibility during critical procedures such as suturing the perineum or neonatal resuscitation, increasing the risk of clinical errors and compromising patient outcomes in the selected rural public hospital theatres. Furthermore, outdated operating theatres often lacked essential equipment, ventilation, or infection control measures, making it difficult for the participants to manage obstetric emergencies with confidence and precision. These physical limitations forced the participants to work in conditions that do not support optimal maternal and newborn care, which undermines their ability to offer both medical and emotional support during labour and delivery. Participants also highlighted that the inconsistent supply of water and electricity in the selected rural public hospital further hinders their capacity to uphold holistic care standards. Frequent power outages disrupt the functioning of essential devices such as foetal monitors, incubators, and sterilisation equipment, while unreliable water supply compromises hygiene, sanitation, and infection prevention protocols. These systemic failures create an unsafe and undignified environment for both patients and healthcare providers, making it difficult for the participants to maintain privacy, cleanliness, and comfort, which are the key components of woman-centred, holistic care. The resulting conditions can heighten anxiety and fear among pregnant women, diminishing their childbirth experience and trust in the health system. For the participants, the emotional and professional toll of delivering care in such constrained environments can lead to burnout and moral distress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eDelayed emergency medical response for maternity care\u003c/h2\u003e \u003cp\u003eMost of the participants were of the same view that delayed ambulance responses during severe obstetric emergencies significantly hindered their work at the selected rural public hospital and obstructed the provision of holistic patient care. In life-threatening situations such as postpartum haemorrhage, obstructed labour, or eclampsia, timely referral to a tertiary hospital is essential for advanced clinical management. However, at the selected rural public hospital setting, ambulance delays are frequent due to poor road infrastructure, limited availability of emergency vehicles, and inadequate coordination within the referral system. Most doctors also live in town, which is approximately a 30-kilometre distance. These delays left the participants with limited options to manage complex emergencies, forcing them to operate beyond their clinical scope of practice in a poorly equipped environment. Furthermore, the inability to transfer critical obstetric emergencies promptly places immense emotional and ethical pressure on the participants, impacting their capacity to deliver holistic, person-centred care. The participants were often left to manage deteriorating clinical conditions without the necessary resources or specialist support, leading to moral distress and a sense of professional helplessness. These conditions can hinder their ability to provide psychological and emotional care to both the patient and her family, especially in situations where outcomes are uncertain or adverse. For mothers and their families, the experience of waiting for delayed emergency transport under stressful conditions can induce anxiety, trauma, and a loss of trust in the healthcare system [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eMidwives in the selected rural public hospital face unique and compounding challenges that necessitate greater support. Rural facilities often operate with critically low staffing levels, resulting in heavy workloads, fragmented care, and minimal time for personalised, woman-centred support [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These shortages are further compounded by limited access to essential resources, outdated infrastructure, and delayed referral systems, all of which compromise the quality and safety of maternal and neonatal care [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Unlike urban hospitals, which typically have higher staff-to-patient ratios, specialised support services, and better-equipped facilities, rural hospitals must deliver the same level of care with significantly fewer resources [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Providing enhanced staffing, targeted training, and improved infrastructure in rural public hospitals is therefore not only a matter of equity but also a critical strategy to reduce preventable maternal and neonatal morbidity and mortality, ensuring that women in remote areas receive the same standard of care as those in urban centres [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The research study was conducted in accordance with the ethical principles of the Declaration of Helsinki, the South African Health Act (Act 61 of 2003) and the Department of health ethics in health research guidelines.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC: Antenatal Care; BNSc: Bachelor\u0026rsquo;s degree in nursing science; BP: Blood Pressure; CEO: Chief Executive Officer; CPAP: Continuous Positive Airway Pressure; CPDs: Continuing Professional Development; CTG: Cardiotocograph; DOH: Department of Health; EMS: Emergency Medical Services; FGD: Focused Group Discussion; HIV: Human Immunodeficiency Virus; HREC: Human Research Ethics Committee; ICM: International Conference of Midwives; NGO: Non-governmental Organisation; NHI: National Health Insurance; NuMIQ: Quality in Nursing and Midwifery Research; NWU: North West University; PNC: Postnatal Care; POPI: Protection of Personal Information; SANC: South African Nursing Council; SRC: Scientific Review Committee; Stats SA: Statistics South Africa; WHO: World Health Organisation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eDeclaration of Helsinki\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Declaration of Helsinki to this effect in the \u0026lsquo;Ethics approval and consent was fully given by participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe NWU, Quality in Nursing and Midwifery (NuMIQ)and the NWU Health Research Ethics Committee approved this study with reference number (NWU-00191-23-A1). After providing all the details of the research study, the written informed consent was obtained from all the participants. All the participants were informed of their right to withdraw from the research study at any time. Privacy and confidentiality of the participants were ensured throughout.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Department of Health (Northern Cape, South Africa).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eResearch reference number: NC_202404_002. This reference number was used for all communication with the research coordinator.\u003c/li\u003e\n \u003cli\u003eThe approval was valid for one year after from the date it was issued.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eThe following was noted:\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eThe project had to only be conducted at no cost to the Northern Cape Department of Health.\u003c/li\u003e\n \u003cli\u003eThe approval had to be limited to the research proposal submitted on the application.\u003c/li\u003e\n \u003cli\u003eThere must be no modifications or amendments to the research project.\u003c/li\u003e\n \u003cli\u003eThe research unit may monitor this research project at any time.\u003c/li\u003e\n \u003cli\u003eAt the completion of this research project, a copy of the final report must be submitted to the research unit.\u003c/li\u003e\n \u003cli\u003eThe Northern Cape Department of Health Senior Management must be briefed on the outcome of the study before publishing.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp id=\"_Toc215115830\"\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp id=\"_Toc215115831\"\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe corresponding author will make available the data supporting the conclusion of this article upon reasonable request.\u003c/p\u003e\n\u003cp id=\"_Toc215115832\"\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNo financial gain was acquired by the authors from this study.\u003c/p\u003e\n\u003cp id=\"_Toc215115833\"\u003eAuthor details\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eNorth West University, Mahikeng City, North West Province, South Africa. \u003csup\u003e2\u003c/sup\u003e North West University, Mahikeng City, North West Province, South Africa. \u003csup\u003e3\u003c/sup\u003e North West University, Mahikeng City, North West Province, South Africa.\u003c/p\u003e\n\u003cp id=\"_Toc215115834\"\u003eAuthors contributions\u003c/p\u003e\n\u003cp\u003eCONCEPTUALISATION, M.B.M, R.M.M., AND S.S.MP; METHODOLOGY, M.B.M, R.M.M., AND S.S.MP; DATA COLLECTION M.B.M.; FORMAL ANALYSIS, M.B.M, R.M.M.; S.S.MP.; RESOURCES, M.B.M; WRITING, M.B.M, WRITING, REVIEW AND EDITING, M.B.M, R.M.M., AND S.S.MP.; SUPERVISION, R.M.M AND S.S.MP.; PROJECT ADMINISTRATION, M.B.M,. ALL AUTHORS HAVE READ AND AGREED TO THE PUBLISHED VERSION OF THE MANUSCRIPT.\u003c/p\u003e\n\u003cp id=\"_Toc215115835\"\u003eAuthors country of affiliation\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eMotheo Bargio Morena, South Africa, Mahikeng City, North West Province, North West University.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eSalaminah S. MolokoPhiri, South Africa, Mahikeng City, North West Province, North West University.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eRorisang M. Machailo, South Africa, Mahikeng City, North West Province, North West University.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe wish to acknowledge the management and midwives of the selected rural public hospital for the permission and unwavering participation in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData analysis: Prof M. Rakhudu.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLanguage review and editing: Ms Jeri-Lee Mowers (Research Advisory Institute of SA). \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdatara P, Amooba PA, Afaya A, Salia SM, Avane MA, Kuug A, Maalman RS, Atakro CA, Attachie IT, Atachie C. Challenges experienced by midwives working in rural communities in the Upper East Region of Ghana: a qualitative study. BMC Pregnancy Childbirth. 2021;21(1):287.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmod HB, Ndlovu L, Brysiewicz P. Clinical mentorship of midwifery students: The perceptions of registered midwives. Health SA Gesondheid. 2024;29:2492.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloxsome D, Bayes S, Ireson D. I love being a midwife; it's who I am: a Glaserian grounded theory study of why midwives stay in midwifery. 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What prevents pregnant women from adhering to the continuum of maternal care? Evidence on interrelated mechanisms from a cohort study in Kenya.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Enablers, barriers, maternal healthcare worker, quality healthcare, rural public hospital","lastPublishedDoi":"10.21203/rs.3.rs-8243812/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8243812/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMidwives who practice in rural public hospitals mostly depend on each other during work. Continuous clinical development improves their skills when managing pregnant women from antenatal to postnatal care. This study aimed to explore and describe the midwives\u0026rsquo; adjustment to enablers and barriers of quality maternal healthcare in a selected rural public hospital in the Northern Cape Province, South Africa, and how quality assurance can be maintained throughout.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative, exploratory, descriptive, and contextual approach was used. Data was collected through focused group discussions, using a semi-structured interview guide, adopting a non-probability purposive sampling technique of 23 participants (midwives and accoucheurs) with at least one year of working in the maternity ward at a selected rural public hospital in Northern Cape Province, South Africa. A thematic data analysis was used, with trustworthiness ensured through dependability, confirmability, credibility, transferability, and authenticity. Ethical considerations were maintained.\u003c/p\u003e\u003ch2\u003eFindings:\u003c/h2\u003e \u003cp\u003eTwo main themes were identified, namely Theme 1: midwives\u0026rsquo; adjustment to enablers of quality maternal healthcare, with two sub-themes: passion for midwifery and continuous teamwork, including consistent learning and clinical development in midwifery. Theme 2, midwives\u0026rsquo; barrier to quality maternal healthcare, identified four sub-themes: lack of human resources, lack of material resources, inadequate and outdated hospital infrastructure and delayed emergency medical response for maternity care.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMidwives mostly rely on their passion and teamwork for maternal health services. Cooperative efforts contribute to providing quality healthcare to the mother and child, regardless of the negative experiences. Challenges such as lack of equipment, inadequate midwives, outdated hospital infrastructure and delayed emergency medical response for maternal healthcare form part of the barriers to quality maternal health care. Even though midwives are equipped with skills in caring for the mother and child through antenatal, intrapartum and postnatal care, many barriers still limit them from providing holistic quality nursing care. Therefore, fundamental support is still needed to improve the midwives at the selected rural public hospital.\u003c/p\u003e","manuscriptTitle":"Midwives’ perceptions of enablers and barriers of quality maternal healthcare in a rural public hospital in the Northern Cape Province","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 13:40:46","doi":"10.21203/rs.3.rs-8243812/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-22T21:40:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169415579076682805825200803774966592750","date":"2026-02-05T14:08:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T13:38:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-31T04:30:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-23T05:23:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-23T00:41:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-12-23T00:35:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fd8228be-7cd5-4c9a-8f02-d3aeb9071717","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-23T13:40:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 13:40:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8243812","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8243812","identity":"rs-8243812","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}